WA Missing Medications Inquiry

The Western Australia Corruption and Crime Commission's Report on serious misconduct risks around drugs in hospitals follows its 2017 report on the Supply and Management of Schedule 8 Controlled Drugs at Certain Public Hospitals in Western Australia, triggered by the repeated theft of drugs by a senior pharmacist at Fiona Stanley Hospital (FSH).

The new report is

a supplement to the Commission's June 2017 report. The purpose of this report is to consider more broadly the issue of theft and misuse of dangerous and addictive pharmaceutical drugs by employees of WA Health, and provide advice and recommendations about ways to prevent serious misconduct. The Boards of WA Health's five Health Service Providers are responsible for the management and security of Schedule 8 and Schedule 4 Restricted drugs held in their hospitals and other facilities, and for mitigating the risks that can arise from the theft and abuse of these drugs. This report's primary purpose is to assist those Boards in their management of the serious misconduct risk inherent in discrepancies of dangerous drugs.

The Commission states

This report analyses notifications received from WA Health about discrepancies for Schedule 8 and Schedule 4 Restricted drugs for the period 1 July 2013 to 30 June 2017 from three major metropolitan hospitals, Royal Perth Hospital (RPH), SCGH, and Fremantle Hospital (FH). These hospitals reported the majority of drug discrepancies. The analysis does not include FSH as issues relating to drug security procedures there were considered in the Commission's June 2017 report. There are common themes or patterns of drug discrepancies arising from the notifications which might guide WA Health in its efforts to deal with this problem. Relevant documents including legislation, WA Health policies and investigation reports have been considered. 

A literature review has been conducted of research nationally and internationally on drug security in hospitals, drug addiction among health professionals and the misuse of pharmaceutical drugs in the community. In preparing this report, the Commission has referred to several reports on the same, or similar topics. These include the following:

• A report by the Commission titled Misconduct Handling Procedures in the Western Australian Public Sector: WA Health, tabled in Parliament on 22 April 2010. This report was based on interviews with a wide range of WA Health employees and a survey. 

• A report by the WA Auditor General titled Pharmaceuticals: Purchase and Management of Pharmaceuticals in Public Hospitals, Report 7, June 2012. 

• Inquests by the WA Coroner in July 2013 into the separate deaths of two WA Health nurses in 2009 and 2010. The inquests revealed that both nurses died from an overdose of drugs, almost certainly accessed from the hospitals at which they worked. 

• The Commission's June 2017 report was based on the investigation by the Commission of the theft of drugs from the pharmacy at FSH.

The investigation included examinations with senior WA Health officers and site inspections. The Commission provided a draft of this report to the Department of Health. Representations have been received from the Director General, from the Medicines and Poisons Regulation Branch of the Department, and from the five Health Service Providers. The Commission thanks those agencies for their comments. Where relevant, they have either been incorporated into this report, or are noted.

It offers the following conclusions

While the total number of drug discrepancies notified to the Commission by WA Health is small compared to the total number of drug transactions in hospitals, it appears that theft and misuse of dangerous drugs by employees is an ongoing problem. WA Health's policies guiding employees on the management and recording of dangerous drugs have in practice, often not been complied with or not enforced. 

As a result, there have been gaps in the records and shortfalls in the security of drugs, which means that in many of the cases notified to the Commission, WA Health has been unable to determine whether a drug discrepancy is accidental or the result of theft and, if so, who was responsible. Drug discrepancies and instances of drug related behaviour have sometimes been investigated by health professionals or human resources officers rather than by professional investigators. This can increase the difficulty in identifying the reason for the discrepancy and, if there has been a theft, in collecting evidence which will enable the person responsible to be identified and dealt with by a criminal or disciplinary process. WA Health has been inclined to deal with employees with drug offending behaviour from a welfare perspective, which may not sufficiently prevent future risks to patients and colleagues.

The report in discussing concerns about failure to notify comments

Notifications were made by WA Health for matters occurring at 50 health service sites. Given that there are 85 hospitals and a large number of other WA Health sites, either there are many sites at which there have been either no unexplained drug discrepancies in the four year period, or possible under-reporting. Many WA Health sites are small, with limited staff and with lower stocks of dangerous drugs. 

However, evidence of under-reporting at WA Health has been identified by the Commission in the past. During the Commission's 2009 review, some employees described a workplace attitude that, because employees worked long demanding hours in difficult conditions, there was a sense of entitlement about taking items, including drugs. 

Employees also admitted they had previously withheld information about possible misconduct because of loyalty to co-workers and fear of retribution:

... staff know that if you 'blow the whistle' you know they won't make life easy for you ... staff would put their head in the sand ... there's a fear of retribution when it comes to reporting misconduct ...

Research has attempted to explore the underlying reasons why health professionals are inclined not to report workplace misconduct. A 2004 study examining a case in which four nurses went public with their concerns about hospitals in NSW, found that although nurses were obligated by codes of ethics to take action to protect patient safety, there are risks. It referred to other case studies recorded by the same author (a Professor of Nursing) and said 'Nurses who blow the whistle often end up with their careers and lives in tatters'. 

Possible reasons for health professionals not reporting their co-workers can include reluctance to tarnish their employer or the health system, fear of the judgment of others, of implicating a friend, or of losing their job. 

A current review of WA Health's investigation reports suggests that WAHealth may still be an environment where there is little encouragement or support for employees to either understand the seriousness of drug related misconduct, or to report it. 

For example, in one notification, it was explained that a nurse suspected to be linked to a number of drug discrepancies had repeatedly displayed past behaviours which raised a number of his colleagues' concerns:

• He had circumvented drug handling policies, such as drawing up drugs in excess amounts without witnesses. 

• He deliberately disobeyed managerial restrictions relating to drug access and entered medical procedure rooms when allocated duties elsewhere. 

• He consistently requested to go into procedure rooms and be involved in duties involving drugs. 

• He was present shortly before drug substitutions and discrepancies were detected. 

• He drew up syringes of fentanyl well before they were required for a medical procedure and without another nurse present, which is against policy. 

• He had been seen near the sharps container removing syringes, some of which would contain unused amounts of fentanyl and midazolam. 

• He was constantly seen staring at drug cabinets. 

• He forged a medical certificate to cover his absences. 

• On one occasion, while on duty, he appeared drowsy and incoherent and then lost consciousness. He was admitted to the emergency department. When his next of kin was advised, they asked "has he been self-medicating again?". On this day, two crushed ampoules containing fentanyl and midazolam were discovered without any evidence of an accidental spillage. 

• He called in sick when a staff meeting about suspected internal drug theft was organised. His close friend, who also worked in the health service, asked questions during the staff meeting such as "what would happen to the person concerned if caught?".

 A clinical consultant said she was approached by "many nurses and a few of the doctors" who expressed their suspicions about the nurse. She went to the Acting Director of Nursing who she believes took the matter up but was told that the nurse was to "remain where he was". The Commission understands that the nurse was reprimanded and warned but remained employed and accredited. 

The recent investigation by the Commission of a WA Health senior pharmacist for stealing Schedule 8 drugs from FSH also demonstrated the risk of colleagues not having the confidence to treat discrepancies as misconduct:

"Didn’t tell them I was suspecting because I find it's not appropriate to point finger. ... It's also a matter of trust. You know we trust them so much ... it’s a highly trusted job. ... I was scared about my - the pharmacists health. I thought that he might kill himself. I thought maybe he's an addict ... and we need to help him. The first thinking was oh my god we need to help him, he, you know, could kill himself   overdosing, because we hear every now and then in news that, okay, this person killed themselves. You know, people working in hospitals."

In a hospital environment, there is a risk that disparities of power between employees may influence internal reporting. Lower level staff may be less inclined to report higher level staff, and certain professionals may be less likely to be questioned. It is important that WA Health recognises this risk when developing and implementing strategies to encourage the reporting of drug related misconduct. 

Regardless whether an agency has an effective process for reporting externally to the Commission or to police, unless employees are prepared to report internally, the agency will not be aware of the issues. 

While the Commission understands the desire for colleagues and mangers to think first about the welfare of the employee, suspected theft of, and misuse of drugs may be serious misconduct and must be notified to the Commission.